An estimated 90% of deaths from pneumonia and influenza occur each year in the United States among adults aged greater than or equal to 65 years. Despite the substantial impact of these and other vaccine-preventable diseases on older adults, national vaccination levels are suboptimal and disproportionately lower among some racial/ethnic minorities than among others. For example, in 1995, influenza and pneumococcal vaccination rates for older Hispanics (50.0% and 24.2%, respectively) were substantially lower than those for non-Hispanic whites (60.1% and 37.4%, respectively) (1). To develop and implement community-based activities to increase vaccination levels among older Hispanic adults in Los Angeles County, California, the Edward R. Roybal Institute for Applied Gerontology at California State University, Los Angeles, formed a community consortium involving multiple public and private organizations. During August-November 1996, this consortium, in collaboration with the Center for the Study of Latino Health at the University of California, Los Angeles (UCLA), conducted a telephone survey to assess vaccination knowledge, attitudes, and practices of older Hispanic adults and to provide baseline information for developing interventions. This report summarizes the results of the initial assessment conducted in two geographic areas; the findings document low vaccination levels among the populations surveyed and race/ethnicity-specific differences in barriers to vaccination and places where vaccinations were received.

Target (for future interventions) and control areas matched for demographic characteristics were selected in areas of east Los Angeles (65% Hispanic, 25% non-Hispanic white, and 10% other races/ethnicities) and 20 miles away in San Fernando Valley (65% Hispanic and 35% other races/ethnicities). The survey targeted samples of 300 Hispanic and 300 non-Hispanic white older adults (aged greater than or equal to 65 years) in each of the two areas; because interventions had not been implemented at the time of the survey, data from the two areas were combined for this analysis. Households were selected using random-digit-dialing; one eligible person aged greater than or equal to 65 years was interviewed in each household.

The survey instrument was translated from English into Spanish, then back-translated into English and field tested. Bilingual interviewers were trained to administer the instrument. A total of 1371 eligible households were screened to achieve the goal of approximately 1200 total respondents (172 households declined to participate or could not be included). The proportion of Hispanic respondents who chose to be interviewed in Spanish was similar in the target (81%) and control (80%) areas. Because data were similar for influenza, pneumococcal, and tetanus vaccination, data are presented only for influenza vaccination.

Sex and age distributions were similar for Hispanics and non-Hispanic whites. However, Hispanics were less likely to report having completed high school (24% {95% confidence interval (CI)=20%-27%}) and were more likely to report an annual family income of less than $30,000 (90% {95% CI=87%-93%}) than were non-Hispanic whites (80% {95% CI=77%-84%} and 69% {95% CI=65%-73%}, respectively).

Vaccination levels were similar for Hispanics and non-Hispanic whites (Table_1). Hispanics were more likely to receive influenza vaccination at a county facility (21% {95% CI=17%-25%}) or hospital (26% {95% CI=21%-30%}) than non-Hispanic whites (3% {95% CI=1%-4%} and 17% {95% CI=13%-20%}, respectively). In addition, Hispanics were less likely to receive vaccinations in a private physician's office or managed-care settings than non-Hispanic whites. Small proportions of both Hispanics and non-Hispanic whites reported receiving vaccinations at senior centers, recreation/community centers, and other settings.

The most common reasons reported by both groups for receiving influenza vaccine included recommendation by a physician, fear of developing disease, and offering of vaccines at a clinic (Table_1). Hispanics were more likely to report receipt of vaccination because of fear of developing disease, because they never had received vaccine, because their spouse suggested vaccination, or because friends or family members suggested vaccination.

The most common reasons reported by both groups for not receiving influenza vaccine were belief of no need for the vaccine, having no knowledge of the vaccine, not being informed by a physician of the need for vaccine, concern that the vaccine would cause illness, and belief of vaccine ineffectiveness (Table_1). Compared with non-Hispanic whites, Hispanics were less likely to believe the vaccine was ineffective or could cause illness and were more likely to report lack of transportation to vaccination sites and inability to afford vaccination. Hispanics also reported that health provider's lack of fluency in Spanish was one reason for nonvaccination.

Reported by: DE Hayes-Bautista, PhD, P Hsu, M Hayes-Bautista, MPH, Center for the Study of Latino Health, E Fielder, DrPH, Institute for Social Science Research, Univ of California, Los Angeles; J Lambrinos, MA, C Reyes, Roybal Institute for Applied Gerontology, California State Univ. Adult Vaccine-Preventable Diseases Br, Epidemiology and Surveillance Div, and Immunization Svcs Div, National Immunization Program, CDC.

Editorial Note

Editorial Note: Vaccination-related national health objectives for adults for 2000 are 1) to increase to at least 60% influenza and pneumococcal vaccination levels for noninstitutionalized persons at high risk for complications from pneumococcal disease and influenza, including those aged greater than or equal to 65 years and 2) to increase to at least 40% the proportion of adults who have received tetanus vaccination during the preceding 10 years (2; objectives 20.11 and 21.2). The findings in this report document low levels of self-reported vaccination against influenza, pneumococcal disease, and tetanus in selected Hispanic and non-Hispanic white populations in the Los Angeles area. The influenza and pneumococcal vaccination levels reported for the non-Hispanic white populations surveyed (39% and 21%, respectively) were lower than statewide levels among non-Hispanic whites as measured by the 1995 California Behavioral Risk Factor Surveillance System (BRFSS) (60% and 46%, respectively) (CDC, unpublished data, 1996), while levels for the Hispanic populations (38% and 16%, respectively) were similar to state estimates (48% and 20%, respectively). Reasons for not receiving influenza vaccine as documented in this survey are consistent with previous assessments of vaccination behavior (e.g., the perception of not needing vaccination, lack of a physician recommendation, concern about adverse events following vaccination, and perception of vaccine ineffectiveness) (3-5). Reasons for the race-/ethnicity-specific differences in places where vaccination services were obtained and financial and physical barriers to receipt of vaccination services may have been associated with socioeconomic factors (e.g., Hispanics reported lower family income than non-Hispanic whites).

This assessment represents the first phase of steps recommended by the community consortium to enhance vaccination levels in the Hispanic community and emphasizes the usefulness and importance of involving community members in developing health promotions and prevention activities. The community consortium is working with local and state public health officials to remove barriers to vaccination and has established a dialogue among community members about issues affecting vaccination of older adults. For example, data from this assessment have been used to customize vaccination services in community vaccination campaigns, educational mailings to the public in both Spanish and English about the availability of vaccination services, reminders to health-care providers about the importance of vaccination, and a Spanish language public service announcement about available vaccination services. A second survey was conducted in mid-1997 to assess changes in vaccination levels and the impact of these interventions; however, the data are not yet available for analysis. In addition, plans have been developed to improve outreach methods, scheduling practices, and Spanish language services and to increase availability of adult vaccination services.

References

1. CDC. Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years -- United States, 1995. MMWR 1997;46:913-9.

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

3. CDC. Adult immunization: knowledge, attitudes, and practices -- DeKalb and Fulton counties, Georgia, 1988. MMWR 1988;37:657-61.

4. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination: knowledge, attitudes, and behavior among high-risk outpatients. Arch Intern Med 1992;152:106-10.

5. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med 1991;91:393-400.

TABLE 1. Percentage of persons aged >=65 years who reported vaccination knowledge, attitudes, and practices, by
race/ethnicity -- Los Angeles County, California, 1996
========================================================================================================================
                                                                   Hispanic               White, non-Hispanic
                                                              ---------------------      ----------------------
Category                                                       %         (95% CI+)          %     (95% CI)
------------------------------------------------------------------------------------------------------------------------
Receipt of vaccination
Influenza&                                                     38        (34%-43%)         39    (35%-43%)
Pneumococcal@                                                  16        (13%-19%)         21    (18%-24%)
Tetanus**                                                      43        (39%-47%)         44    (40%-48%)
Settings where received influenza vaccination
County clinic                                                  21        (17%-25%)          3    ( 1%- 4%)
Hospital                                                       26        (21%-30%)         17    (13%-20%)
Private physician                                              27        (23%-32%)         42    (37%-47%)
Health maintenance organization                                16        (13%-20%)         28    (24%-32%)
Senior center                                                   2        ( 1%- 3%)          4    ( 2%- 6%)
Recreation center                                               2        ( 0%- 3%)          1    ( 0%- 2%)
Health fair                                                     2        ( 0%- 3%)          1    ( 0%- 2%)
Church                                                          0               --          1    ( 0%- 2%)
Injectionist++                                                  2        ( 1%- 4%)          2    ( 1%- 4%)
Reported reasons for receiving vaccine
Physician recommended                                          78        (74%-82%)         71    (67%-75%)
Fear of developing disease                                     76        (72%-80%)         60    (56%-64%)
Clinic offered vaccine                                         60        (55%-64%)         52    (48%-57%)
Never had vaccination/Thought vaccination was a good           45        (40%-50%)         19    (15%-23%)
idea
Spouse suggested vaccination                                   17        (13%-21%)          9    ( 6%-12%)
Friends or family suggested vaccination                        17        (13%-20%)          8    ( 6%-10%)
Spouse had been vaccinated                                     15        (11%-19%)         13    (10%-16%)
Friends or family had been vaccinated                          11        ( 8%-14%)          7    ( 4%- 9%)
Informed about vaccination at senior center                    11        ( 8%-14%)          7    ( 5%-10%)
Reported reasons for not receiving vaccine
Believed that vaccination was not needed                       52        (45%-58%)         62    (54%-70%)
Had no knowledge of the vaccine                                47        (40%-53%)         19    (13%-26%)
Physician did not inform about need for vaccination            41        (34%-48%)         39    (31%-47%)
Vaccine too expensive                                          33        (26%-39%)          5    ( 1%- 9%)
Did not know where to obtain vaccination                       28        (21%-34%)          7    ( 3%-11%)
Provider did not speak Spanish                                 26        (20%-31%)          0        --
No transportation                                              23        (17%-29%)          6    ( 2%-10%)
Concern that vaccine would cause illness                       22        (16%-27%)         46    (38%-54%)
Poor hours at clinic                                           21        (15%-26%)          3    ( 0%- 6%)
Doubt of effectiveness of vaccine                              19        (13%-24%)         39    (31%-47%)
Long wait for appointment                                      16        (11%-21%)          1    ( 0%- 2%)
Long clinic wait                                               14        ( 9%-18%)          1    ( 0%- 2%)
------------------------------------------------------------------------------------------------------------------------
*  n=1199
+  Confidence interval.
&  Respondents were asked whether they had received influenza vaccination during the preceding year (i.e.,
   October 1995-September 1996).
@  Respondents were asked whether they had ever received pneumococcal vaccination.
** Respondents were asked whether they had received tetanus vaccination during the preceding 10 years.
++ An unlicensed layperson who provides various types of injections.
========================================================================================================================

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